MILEAGE REIMBURSEMENT FORM

______________________                                                    ________________________

    EMPLOYEE NAME                                                                      PHYSICIAN’S NAME

______________________                                                    ________________________

   DATE OF ACCIDENT                                                                              ADDRESS

______________________                                                    ________________________

        FILE NUMBER                                                                                    ADDRESS

IN ORDER TO OBTAIN REIMBURSEMENT FOR MILEAGE RELATED TO A VISIT TO YOUR TREATING PHYSICIAN, IT IS NECESSARY THAT THE FORM BELOW BE COMPLETED, SIGNED BY THE PHYSICIAN AND SUBMITTED TO F.A. RICHARD & ASSOCIATES, INC.

DATE OF                                DESTINATION:                                ROUND TRIP           

   VISIT                               TO                          FROM                        MILEAGE

1. __________         _____________           ______________        _______________

2. __________         _____________           ______________        _______________

3. __________         _____________           ______________        _______________

4. __________         _____________           ______________        _______________

5. __________         _____________           ______________        _______________

6. __________         _____________           ______________        _______________

                                                                                          TOTAL   _______________

___________________________

   PHYSICIAN’S SIGNATURE

18 U.S. CODE SECTION 1001

FRAUD AND FALSE STATEMENTS

WHOEVER IN ANY MATTER WITHIN THE JURISDICTION OF ANY DEPARTMENT OR AGENCY OF THE UNITED STATES KNOWINGLY AND WILLFULLY FALSIFIES, CONCEALS, OR COVERS UP BY ANY TRICK, SCHEME, OR DEVICE A MATERIAL FACT OR MAKES ANY FALSE, FICTITIOUS, OR FRAUDULENT STATEMENTS OF MISREPRESENTATIONS OR MAKES OR USES ANY FALSE WRITING OR DOCUMENT KNOWING THE SAME TO CONTAIN ANY FALSE, FICTITIOUS, OR FRAUDULENT STATEMENT OR ENTRY SHALL BE FINED NOT MORE THAN $10,000 OR IMPRISONED NOT MORE THAN FIVE YEARS OR BOTH.

___________________________                      ________________________

CLAIMANT’S SIGNATURE                                                          DATE

APPROVED FOR PAYMENT BY: _____________________                ___________

                                                                                                                                 DATE

__________________X__________________=__________________ AMOUNT DUE